More Generics And Negotiating Leverage Could Slow Medicare Drug Spending

An independent commission recommended changes to Medicare Part D, including reducing or waiving copayments for generic drugs for low-income enrollees.

An independent commission recommended changes to Medicare Part D, including reducing or waiving copayments for generic drugs for low-income enrollees. Shana Novak/Getty Images hide caption

toggle caption Shana Novak/Getty Images

Congress should move to slow spending in Medicare’s drug benefit by adopting a package of changes that could save billions of dollars, but that would also add costs for insurers and have mixed effects on enrollees, an independent advisory commission said Wednesday.

The Medicare Payment Advisory Commission warned in its June report to Congress that rising drug costs and other factors helped drive Medicare Part D spending up nearly 60 percent between 2007 and 2014.

MedPAC recommendations are considered influential, but don’t expect Congress to pursue those changes during an election year.

Still, the commission makes proposals it estimates could save at least $10 billion over five years, partly by encouraging more use of generic drugs and also by creating incentives for insurers to negotiate better prices from drug makers.

The proposals would:

  • Sharply reduce or even eliminate the copayments that about 12 million low-income Medicare enrollees pay for generic drugs — to encourage the use of the lower-cost medications.
  • Create an annual out-of-pocket spending cap for higher-income enrollees that is similar to one already in place for low-income beneficiaries. After enrollees hit the cap, Medicare would cover 100 percent of the cost of their medications.
  • Make it harder to reach that annual cap by not allowing a drug discount given by manufacturers to count toward the enrollees’ out-of-pocket maximum.
  • Require insurers to pay 80 percent of drug costs, up from the current 15 percent, after patients hit the out-of-pocket maximum.

Patient groups like the idea of reducing generic copayments for low-income enrollees and setting an annual cap, yet they fear that the proposal would mean patients would remain in the coverage gap known as the “doughnut hole” for longer periods.

While in the doughnut hole, enrollees pay a higher percentage of drug costs. MedPAC estimates that its proposal would mean about half of beneficiaries whose drug spending is high enough to hit this gap would remain in it longer, paying about $1,000 more each as a result.

“We’re pleased that some of the recommendations would protect beneficiaries from the rising cost of medications … but we have concerns that fewer beneficiaries would benefit from the out-of-pocket maximum,” said Stacy Sanders, federal policy director for the Medicare Rights Center.

Some proposals have been rejected before, but the report could spark discussion under a new administration and Congress in 2017.

“Once MedPAC makes a recommendation, it gives it legitimacy,” Sanders said . “In future years, we could see the proposals as a starting point for some legislation.”

This year, the doughnut hole occurs after patients and their insurers combined have spent $3,310 on covered drugs. In the coverage gap, enrollees must pay a larger share of the cost of their drugs until catastrophic coverage kicks in. That happens when spending hits $4,850 and enrollees then pay 5 percent of the cost of their drugs.

While 5 percent isn’t much when a low-cost generic is taken, it can be substantial for expensive drugs, such as many used to treat hepatitis, cancer, multiple sclerosis and some forms of arthritis.

The Affordable Care Act gradually phases out the coverage gap by requiring drug makers to give enrollees discounts. This year, the discount is 50 percent of the cost of the drug. Even though enrollees are not paying that discounted amount out of their own pockets, the ACA allowed the dollar value to count toward the $4,850 threshold for catastrophic coverage to begin. Since the ACA took effect, the number of Medicare Part D enrollees who reach the catastrophic coverage level has grown from 400,000 in 2010 to 700,000 by 2013, according to MedPAC. That shift costs Medicare and taxpayers more because the program pays 80 percent of the costs for drugs after enrollees go through the coverage gap.

Under the commission’s proposal, enrollees would no longer be allowed to count those drugmaker discounts toward the total, meaning it would take longer to hit the out-of-pocket cap. Indeed, about half of enrollees might not reach the threshold in a given year and not benefit from the 100 percent coverage, the report notes.

“For many people, this will actually increase spending,” said Caroline Pearson of consulting firm Avalere in Washington, D.C., which is in the process of analyzing the financial impacts of the MedPAC proposals. “While our results aren’t finalized yet, our generalized finding is that a small number of beneficiaries would save a lot of money … but a lot would spend more.”

Other elements of the proposal would affect insurers. MedPAC recommends insurers shoulder more of the cost of prescriptions after enrollees exit the doughnut hole. That would encourage insurers to try to keep enrollees from hitting the coverage gap’s upper limit by getting them to choose lower-cost drugs or by driving harder bargains with drug makers, said Mark Miller, executive director of the commission.

“A good portion of that payment is because beneficiaries are either using more expensive drugs or the prices of their drugs are going up relatively aggressively,” said Miller. “We’re trying to say … you’re going to want to negotiate as tough prices as you can.”

MedPAC says the proposals are needed because rising drug prices and other factors helped drive spending in the program to $73 billion in 2014 – and more high-cost drugs will hit the market soon. Without action, the rising costs could drive up program costs and probably premiums for enrollees, MedPAC said.

When MedPAC adopted its recommendations unanimously this spring, they drew mixed reviews and many comments from the drug industry, consumer groups and insurers. All the groups found elements they liked in the plans and parts they opposed.

Little change was seen in the final version released to Congress.

“PhRMA remains concerned about the sweeping recommendations MedPAC approved in April and opposes changes to Medicare Part D that taken together could harm beneficiaries by eroding coverage and protections for many of the most vulnerable enrollees in the program,” said Allyson Funk, spokeswoman for the drug industry’s trade group PhRMA.

Kaiser Health News is a service of the nonprofit Kaiser Family Foundation. Neither one is affiliated with the health insurer Kaiser Permanente.

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How LGBTQ People Of Color Are Dealing With Orlando: Code Switch Podcast, Episode 4

Young people from Husseini Islamic Center in Sanford, Florida visit a makeshift memorial at the Dr. Phillips Center for Performing Arts, June 14, 2016 in Orlando, Florida.

Young people from Husseini Islamic Center in Sanford, Florida visit a makeshift memorial at the Dr. Phillips Center for Performing Arts, June 14, 2016 in Orlando, Florida. Drew Angerer/Getty Images hide caption

toggle caption Drew Angerer/Getty Images

The attack on a largely Latino crowd at a gay nightclub in Orlando by a Muslim American mass shooter has meant different things to different people. The devastation cuts across many facets of culture, identity, and community.

This episode, we spoke to:

We wanted to speak to people who might be feeling this most acutely — folks who belong to the LGBTQ and Latino communities that were disproportionately affected, folks who shared the shooter’s Muslim background, and people whose identities fall somewhere in both camps.

For this week’s episode, we talked to Carlos Guillermo Smith, a resident of Orlando and a member of the LGBT Civil Rights group Equality Florida. Smith has been in the thick of all this, organizing vigils, talking to the media, and acting as a pillar of support for his community in Orlando.

Although he’s been running around a lot the past few days, he shared with us a quiet moment — the first time that he was able to sit down and begin to process all that’s happened.

“We all just grabbed each other and held onto each other and tried to take a second to appreciate that we were all still on this earth together,” he told us.

We also checked in with Code Switch reporter Adrian Florido, who’s spent the past few days in Orlando, listening to the stories of friends and loved ones of Puerto Rican victims of Sunday’s attack. He talked to us about how this attack has made some Latinos feel even more isolated from the American identity that they’ve been trying to so hard to inhabit.

Matt Thompson, a Code Switch founder and now deputy editor of, described the way this attack hit home for him. He grew up in Florida, the gay son of immigrant parents.

“Rewind the clock just a bit, and I could have been one of those men in that place,” Thompson said. “That could have been the way my parents found out. And they would’ve had to spend the rest of their lives reckoning with a person that they didn’t know they didn’t know.”

Finally, we spoke to Bilal Qureshi, a freelance journalist, former NPR producer and editor, and an American Muslim. He told us about the anguish he felt after realizing that what should have been a beautiful intersection of cultures had turned into a scene of incredible violence.

“An Afghan-American Muslim walks into a gay club in Florida on Latin night during Pride Month. In my dreams, that is the beginning of another great story of remix, tolerance and coexistence that is possible only in America,” Qureshi wrote in an op-ed for the New York Times. “In reality, it’s the start of a nightmare massacre fueled by hatred and perpetrated by a man from a group already scarred by a generation of suspicion and surveillance.”

We’ll continue to follow this story on the Code Switch blog and on the radio. Listen here.

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WATCH: In Conversation With Oprah, Michelle Obama Tells Men To 'Be Better'


Oprah Winfrey and First Lady Michelle Obama sat down The United State of Women summit earlier this week.

They spoke at length about women’s empowerment and self worth, but their message to men is getting a lot of attention attention. Asked what men attending the summit can do, Obama replied “be better.”

“Be better at everything. Be better fathers, good lord. Just being good fathers who love your daughters, and are providing a solid example of what it means to be a good man in the world and showing them what it feels like to be loved. That is the greatest gift that the men in my life gave to me.”

The fact that she’s never experience abuse at the hands of a man, Obama said, “is sad to say, that’s a rare reality. So men can be better at that.”

Men can also be better husbands, do the dishes, “be engaged … be a part of your families lives.” Obama also called on men to be “a better employer.”

“When you are sitting at a seat of power at a table of any kind and you look around and you just see you — it’s just you and a bunch of men around a table, on a golf course making deals, and you allow that to happen, and you’re OK with that — be better.”

Earlier in the conversation, Obama called on women to get to know themselves and learn to prioritize their own needs — the key to balance, she said. “You know why? Because [men] don’t have to balance anything. Sorry. I hope that that is changing but so many men don’t have to do it all.”

There were also light-hearted moments as Obama spoke about her attraction to her husband. “Good lord. Watching my husband walk off of Marine One and go to the Oval Office, it’s like, mmm, mmm, mmm. And you know he’s got that walk, right?”

“He was very swagalicious.”

Winfrey is a friend of the Obamas and once campaigned for that “swagalicious” president.

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'Locally Laid': A Humorous Memoir To Cure You Of Farming Fantasies

Jason and Lucie Amundsen on their farm in in Wrenshall, Minn.

Jason and Lucie Amundsen on their farm in in Wrenshall, Minn. Katie Cannon hide caption

toggle caption Katie Cannon

If one has to sell a crazy idea, why not over beer and salsa? That’s exactly what Jason Amundsen did four years ago at a Mexican restaurant in Duluth, Minn., when he announced to his wife, Lucie, that he wanted to give up his job and sell eggs.

At the time, Jason was a grant writer for a local hospital; Lucie was a freelance journalist. They had two school-age children to raise and a mortgage to pay. What they knew about chickens could fit in an eggcup with room to spare.

But here was Jason, going into raptures over eggs.

Not any old battery-caged supermarket egg, but “pasture-raised eggs,” he explained to his staggered wife, who gulped her beer down rapidly. These eggs are far superior to “free-range eggs,” he told her. (Not to mention cage-free eggs, which are typically big operations where hens are kept indoors — just not in cages.) For while free-range hens do forage freely under the sun, they are grazed on the same old plot of grass — even after it’s been pecked dry of all its nutrients. Whereas, beamed Jason, pasture-raised hens are rotated on fresh plots wriggling with worms and vitamins. Consequently, he argued, they lay tastier and healthier eggs – which he intended to sell.

Many, many tragicomic months later, Lucie would coin a phrase to describe pasture-raised chickens. She’d call them “salad-eating poultry athletes.” But that was in the distant future. At that moment, she simply lost her temper.

“Start a farm?” she thought to herself furiously. “This is a man who until a few years ago could not identify a pear.”

But start a farm Jason did, and Lucie went along on the ride. The transition, she writes in Locally Laid, her memoir about their grand experiment, was “as subtle as an axe.”

The book gets its title from the mischievously risqué brand name – the Locally Laid Egg Company – the Amundsens chose for their farm. The sexual pun did ruffle the sense of propriety of a few Midwesterners – one irate complainant accused them of adding to the “crudeness in the world” – but on the whole it proved to be a masterstroke. It got the fledgling poultry farm the smiles, winks, attention and social media boost it so desperately needed.

“Our sassy name broke through the media clutter out there,” says Lucie, whose car is emblazoned with the exhortation “Get Locally Laid.” “No one would have given us a second look if we’d called ourselves Amundsen Farms,” she says.

But to return to the beginning: After leasing a plot of farmland in Wrenshall, Minn., outside Duluth, the Amundsen family waited in high excitement for the first pullets to arrive. It turned out to be a baptism by dehydration. The hens were delivered on a boiling June day in 2012, when the annual Grandma’s Marathon had slowed traffic in the town to a crawl. Squashed into crates that had been loaded on an open trailer, the birds were a parched, traumatized, pecked and broken mess, having indulged in an orgy of “bird-on-bird violence” on their long and hot journey. Of the 900 hens, 125 died.

Every chicken on the Locally Laid farm is called LoLa — short for Locally Laid.

Every chicken on the Locally Laid farm is called LoLa — short for Locally Laid. David Paul Schmit/Courtesy of Lucie Amundsen hide caption

toggle caption David Paul Schmit/Courtesy of Lucie Amundsen

The next shock was discovering that these warehouse-bred hens didn’t behave like regular hens. Never having seen the sun, they didn’t know what it was to forage or come home to roost. So, at sundown, the Amundsen family had to chase after each hen, capture it and bring it into the barn.

And that was only a tiny bit of the battle won.

In the barn, the birds feel asleep on the overcrowded floor, ignoring the roosts built for them to perch on – simply because they’d never perched on a roost before. Jason sent his exhausted family home, strapped a headlamp to his forehead and, one by one, gently placed all 775 sleeping hens on their perches – their feet curled automatically over the roosting stick.

The story gets a lot worse before it gets better.

One reads with horrified fascination about the crippling Minnesota winter, when hundreds of eggs froze before they could be collected from the nesting boxes; the byzantine demands by government inspectors; the 16-hour days and bone-deep weariness of running a poultry farm; the broken pumps and farm machinery that constantly required fresh infusions of cash; the moving of the heavy fence to rotate pasture land; the daily feeding, cleaning, and watering of the chickens; the daily crawling through chicken droppings to collect eggs from the nesting boxes; the endless egg-washing of hundreds of eggs every day; the persistent ordure and odor of chicken; and the looming specter of bankruptcy.

Of all the many mistakes these newbie farmers made, their biggest, says Jason, was in not understanding the regulatory environment.

“Although we got the rules from the state of Minnesota regarding egg processing before we got chickens, we did not have a conversation with the inspector in advance,” he told me. “As a result, when the inspector arrived, he said we had received an incomplete set of rules and that we failed. We had to adapt, it wasn’t pretty, and though we eventually passed, it was an expensive and a painful lesson in the necessity of doing more research and planning before getting into business. Sadly, most every business will have some version of this story and you have to be ready to dig really deep and shoulder through these events. There’s just no other way.”

Given the hurdles they had to surmount, the happier stories – and there are many – of how family and friends rallied to aid the beleaguered Amundsens are heartwarming. Friends helped with the egg washing and organized “ovum speakeasies” to help sell eggs that were piling up. And almost all of Duluth rose up to support the farm in a competition to get a free ad spot during the Super Bowl (they didn’t win, but came close). A grateful Lucie calls it “an explosion of community.”

Written with candor, sarcasm and humor, Locally Laid is, to pluck a phrase from the book, an immersion into “a loud, flustery poultry tsunami.” It cures one of any residual romantic notions of playing farmer; makes one appreciate afresh how grueling and risky it is to operate a mid-sized family farm; and explains why their products are more expensive.

It’s scarcely surprising that with each passing year, fewer and fewer individual farmers have the resources or stamina to keep at it, yielding the field to industrial-size egg-laying operations.

Eggs from Locally Laid

Eggs from Locally Laid David Paul Schmit/Courtesy of Lucie Amundsen hide caption

toggle caption David Paul Schmit/Courtesy of Lucie Amundsen

According to the American Egg Board, the number of egg producers in the U.S has plunged from 2,500 in 1987 to 268 in 2015.

But simultaneously, the impact of the locavore and organic food movement, though small, has been significant. The Amundsens have found that a growing number of customers – including several of Duluth’s top chefs – don’t mind paying more for their brown and speckled eggs.

To keep their carbon footprint small, Locally Laid’s eggs are sold only within a 400-mile radius of the farm. “Sometimes this philosophy makes distribution a nightmare,” says Lucie. “When we’ll have a glut of eggs in one region, but can’t bring them to a different buying area because it’s outside of the mileage limit. Then we give them to food shelters. Also, we do other environmental work, like planting a tree with every delivery.”

Today, Locally Laid – along with its seven partner farms in Iowa and Minnesota – sells approximately 38,000 dozen eggs a month. The sense of achievement is enormous. But four years of toil and stress have taken their toll.

“When Jason jokes that the farm was his midlife crisis and it was either that or have an affair,” writes Lucie wryly, “I find myself wondering which would have been more difficult on our family.”

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Latinos At Home And Abroad Mourn After Orlando Shooting

Francheska Garcia remembered her friend, Jonathan Camuy, who was killed in Sunday's mass shooting at the Pulse nightclub in Orlando. Like many Puerto Ricans, Camuy had moved to Florida to escape Puerto Rico's economic crisis.

Francheska Garcia remembered her friend, Jonathan Camuy, who was killed in Sunday’s mass shooting at the Pulse nightclub in Orlando. Like many Puerto Ricans, Camuy had moved to Florida to escape Puerto Rico’s economic crisis. Adrian Florido/NPR hide caption

toggle caption Adrian Florido/NPR

Around a candle-lit altar honoring one of the victims of the mass shooting in Orlando, Anthony Laureano and his friends hold hands, mourn in two languages, and say a prayer:

“Estamos aqui … We’re here together … Porque no somos diferentes … Because we’re not different.”

Realtor Christian West Howard, right, offered up his vacant properties to house the families of victims traveling to Orlando for funerals. His Facebook post garnered a huge response, and by Monday night, he and a group of volunteers were linking families with rooms, rental cars, and travel donated by companies and regular people.

Realtor Christian West Howard, right, offered up his vacant properties to house the families of victims traveling to Orlando for funerals. His Facebook post garnered a huge response, and by Monday night, he and a group of volunteers were linking families with rooms, rental cars, and travel donated by companies and regular people. Adrian Florido/NPR hide caption

toggle caption Adrian Florido/NPR

Nearby, Francheska Garcia holds a collage of photos of her friend Jonathan Camuy. “What I’m going to remember is his smile,” Garcia says. “He was Puerto Rican. Because usually our parents live over there and we’re the rebel ones who move here, to make it on our own.”

Most of those killed in Sunday’s rampage were Latinos — specifically Puerto Ricans.

Camuy moved to Florida two years ago to escape Puerto Rico’s economic crisis, something many Puerto Ricans are doing by the thousands before resettling in Central Florida. Not only is this reinforcing bonds between Orlando and the island, but it also means Sunday’s shooting shattered lives in both places.

Luis Mercado, who works with local Spanish-language TV, spoke in Spanish about Orlando’s Latino community.

“Tu tienes mas personas que estan llegando donde el espanol es su primer idioma, pero si vienes a ver…”

Despite many Puerto Ricans arriving who speak little English, the Puerto Rican community is pretty united.

On Sunday around 3 a.m., Mercado’s phone started going off with messages in both languages. Two of his best friends, Juan Rivera and his partner Luis Condo, were at the Pulse nightclub that night, but there was no news of them.

Luis Mercado with his friends Luis Conde, left, and Juan Rivera, right. Mercado spent hours after the shootings searching for his friends in hospitals, only to find out both had been killed in the shooting.

Luis Mercado with his friends Luis Conde, left, and Juan Rivera, right. Mercado spent hours after the shootings searching for his friends in hospitals, only to find out both had been killed in the shooting. Courtesy Luis Mercado hide caption

toggle caption Courtesy Luis Mercado

Over the next 18 hours, Mercado and his friends’ families went from hospital to hospital, hoping to hear Juan and Luis’ names read from the lists of the injured.

“Pasa un nombre, pasa el segundo, y tu corazon late, y tu esperas que llegue, y no llega. Cuando llegan al final, tu comienzas a llorar. Tu comienzas a llorar porque ellos no estan en esa lista. Y tu sabes que tienen que estar en la otra.”

Your heart is pounding as they read one name after the other, but not theirs. And then they get to the end, and you start to cry. You cry because you realize they must be on the other list.

The list of the dead. Juan and Luis did die. They were among the best known hair stylists in Puerto Rican Orlando. Flowers pile up outside their salon.

Marangely Valdes said ten of her friends were killed in Sunday's shooting at the Pulse nightclub.

Marangely Valdes said ten of her friends were killed in Sunday’s shooting at the Pulse nightclub. Adrian Florido/NPR hide caption

toggle caption Adrian Florido/NPR

For all the unity, the issue of many of the victims’ sexuality is also causing a little tension. One woman called into one of Orlando’s most popular Spanish-language radio stations to say her friend refused to mourn gay victims.

Right now, though, people are focusing on the victims’ families. At a local strip mall, volunteers coordinate travel and lodging for those coming to Orlando for funerals.

Suzanne Gonzalez, one of the volunteers, says offers are coming in from airlines, hotels, and regular people. They’ve even gotten an offer for donated tombstones, and a lawyer who secured an emergency visa for a Dominican mother to come to to her son’s funeral.

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EgyptAir Cockpit Voice Recorder Has Been Recovered, Egyptian Officials Say

Map showing the path of EgyptAir flight 804

Source: FlightAware

Credit: Alyson Hurt/NPR

A ship in the Mediterranean has recovered the cockpit voice recorder from EgyptAir Flight 804 and taken images of “several main locations” of the plane’s wreckage, Egypt’s Civil Aviation Authority says.

The recorder was damaged, the agency said Wednesday, but the search team was able to recover the device’s memory unit.

The recorder and the images were obtained by the ship John Lethbridge, the Civil Aviation Authority says.

The Associated Press reports that the vessel is operated by the U.S. company Deep Ocean Search and arrived at the search area on Sunday. The ship is equipped with underwater detection equipment, such as sonar, that can explore up to 6,000 feet below the sea’s surface.

Flight 804 crashed into the Mediterranean Sea nearly a month ago, killing all 66 people aboard.

What caused the Airbus A320 to crash is still unknown. Investigators are hoping the voice recorder will shed light on what, exactly, happened. The plane’s flight-data recorder has not yet been found.

Some small pieces of debris from the plane had previously been discovered by search crews, but the search continued for the bulk of the wreckage.

The Egyptian Civil Aviation Authority says search teams are now working on mapping the main wreckage locations and discussing how to “best handle the wreckage.”

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Top Stories: CIA Director On ISIS; Russia's Huge, New Icebreaker

Good morning, here are our early stories:

— CIA Director: Battlefield Advances Have Not Degraded ISIS’ Terrorism Potential.

— Russia Launches World’s Biggest, Most Powerful Icebreaker.

And here are more early stories:

Trump Again Calls For Surveillance Of Mosques. (CNN)

Report: World Doping Agency Overlooked Alleged Russian Cheating. (New York Times)

Calif. Utility On Trial In Deadly Gas Explosion. (San Jose Mercury News)

Russia Calls 48-Hour Truce For Northern Syrian City, Aleppo. (AFP)

Report: Ethiopia Allegedly Brutally Repressing Protesters. (Human Rights Watch)

34 Migrants, Mostly Children, Found Dead In Niger Desert. (

South Africa On The 40th Anniversary Of The Soweto Uprising. (Guardian)

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First Watch: Esmé Patterson, 'No River'

June 16, 201610:00 AM ET

A river is life. It is power. And sometimes it rages. In Esmé Patterson‘s new video for her breezy pop anthem “No River,” it’s an unstoppable force, and something she knows she’ll never be. “I can’t keep running,” she sings. “I’m no river … I’m human.” It’s a hymn to the fragile and endlessly flawed human condition.

As the gorgeously shot video opens, Patterson is tethered to a heavy rope and hauled from a placid river blanketed in fog. She’s then joined by a group of other women in a field of flowers; there, they dance together to the rhythms of their own hearts.

“It’s about the freedom that we can find when we surrender to the realization that we are mortal,” Patterson tells NPR Music via email. “By understanding that we are dying, we also understand that we are alive in this very moment. I wanted to represent these themes visually in the music video: the strength and vulnerability of the body, the circadian rhythm of life, the dance with nature, life as a dance.”

“No River” is from Esmé Patterson’s new album, We Were Wild, out now on Grand Jury Music. The video was directed by David Fishel and choreographed by Carlye Eckert.

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CIA Director: Battlefield Advances Have Not Degraded ISIS' Terrorism Potential

CIA Director John Brennan.

CIA Director John Brennan. Andrew Harnik/AP hide caption

toggle caption Andrew Harnik/AP

The director of the Central Intelligence Agency told the Senate Intelligence Committee on Thursday that the U.S. and its allies are making progress on the battlefield against the Islamic State.

But then John Brennan dropped a major caveat.

“Unfortunately, despite all our progress against ISIL on the battlefield and in the financial realm, our efforts have not reduced the group’s terrorism capability and global reach,” Brennan said. “The resources needed for terrorism are very modest, and the group would have to suffer even heavier losses of territory, manpower, and money for its terrorist capacity to decline significantly.”

Brennan said ISIS has lost lots of ground in Iraq and Syria and its finances have been squeezed. ISIL, Brennan said, using another acronym for the group, is on the defensive.

“To compensate for territorial losses, ISIL will probably rely more on guerrilla tactics, including high-profile attacks outside territory it holds,” Brennan said. “A steady stream of attacks in Baghdad and Damascus demonstrates the group’s ability to penetrate deep inside enemy strongholds.”

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CHART: This Primary Season, Clinton Won States With Highest Income Inequality

Hillary Clinton arrives onstage during a primary night rally in Brooklyn on June 7.

Hillary Clinton arrives onstage during a primary night rally in Brooklyn on June 7. Drew Angerer/Getty Images hide caption

toggle caption Drew Angerer/Getty Images

Earlier this year, we noticed a pattern in which states were voting for Hillary Clinton and which were voting for Bernie Sanders in the Democratic nominating contests. Sanders tended to win the states that had the highest income equality (as measured by the Gini index, a widely-used measure of inequality), and Clinton tended to win states that were the most unequal.

Now that the primaries are over, we decided to look again. The trend held relatively well, as it turns out: with her win in the District of Columbia primary on Tuesday, Clinton won the most-unequal place in the nation, according to the Gini index. Sanders, meanwhile, tended to dominate among the more-equal states.

All of which is surprising, given that Sanders built his campaign message around battling inequality. Here’s a look at our chart — this time with D.C. added on. The Washington, D.C., bar is the one on the far right of the chart.

(See our last post on this for our notes on how to interpret this data.)

It’s a fascinating trend, but what does it mean? First off, it doesn’t mean that Sanders’ inequality message didn’t resonate with people — clearly it did. And it doesn’t mean that people chose Clinton or Sanders based on exactly how unequal their state is (it’s the rare voter who knows her state’s Gini coefficient).

Or, as several commenters on a Quora thread about our chart said, it was a case of correlation not equaling causation.

Fair enough — there’s probably not a direct relationship. But there’s good reason to think this isn’t a case of two totally unrelated factors inexplicably tracking together, like Nicolas Cage movies and swimming pool drownings.

Rather, the two phenomena may be connected, though not directly. It may be that those factors that are related to high Gini figures also tend to be factors that contribute to a person voting for Clinton. To briefly recap our last post (see a more extensive explanation here), we highlighted two ways the phenomena might be connected, albeit indirectly.

One is race. The Southern states are a good place to look at this. Clinton was enormously successful in southern states, thanks to heavy support from African-Americans in that region. The South is also the highest-poverty region in the United States, which contributes to that region’s high inequality scores. And of course, there are many, complicated links between poverty and race in America, helping to push the black poverty rate well above the white rate.

Another is rural- or urban-ness. Clinton by far did better in cities than Sanders did, according to a Wall Street Journal analysis. Sanders, meanwhile, did well in rural white counties. In fact, Clinton did far worse in rural white counties this year than she did in 2008, as the Journal found.

There could be a number of reasons why this happened — and of course, race is part of this (Sanders did well in rural white counties, after all). But in addition, Sanders made explicit appeals to rural voters, like his reminders to voters that he is from a rural state and therefore understands their values. One of his tactics was appealing to white working-class voters in places like West Virginia, where other Democrats seemed to have given up hope, as the Washington Post’s Dave Weigel wrote earlier this year.

And it makes sense for rural areas to have lower inequality than urban areas, as urban areas both tend to attract more skilled (and therefore higher-paid) workers, as well as poorer households, in part due to public transit access, as the World Economic Forum‘s Kristian Behrens and Frédéric Robert-Nicoud wrote in 2014.

And those trends taken together may help explain how the people who live in the most equal areas ended up supporting the candidate who more explicitly ran on the economic equality platform.

That said, a big caveat: these are very simple generalizations about how people voted — that is, people think about more than their race or ruralness when they get into the voting booth.

For example, many Southern voters (of any race) are aware of the high poverty in their region. It’s altogether possible that many Southern voters cast their votes based on which candidate they thought could alleviate that poverty. So in some cases, the link between inequality and voting may have been more direct.

One more addendum here is that it’s not totally clear — and may never be — how the AP’s June 6 call that Clinton had clinched the nomination affected the outcomes of the June 7 primaries (in California, Montana, New Jersey, New Mexico, and the Dakotas). Clinton won California and New Jersey that day — two states with high inequality. That call may have either boosted her — or it could have energized Sanders’ voters that day.

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